At least 354 people have died of H1N1 virus infections, more commonly called swine flu, in Gujarat since January this year. In the past week there has been a sudden spike in the number of cases and 79 residents across the state have died in this period alone. However, Gujarat health authorities have not carried out vaccinations against swine flu as the national communicable diseases authority had recommended earlier this year.

In May, the Integrated Disease Surveillance Programme or IDSP identified Gujarat as a high-risk state for the spread of H1N1. The programme found that Gujarat was one of six states that had active transmission – passing of the H1N1 virus between people spreading infection. Despite this warning from the IDSP, Gujarat health authorities say that the surge in cases in August has been “sudden”.

Both the World Health Organisation and the India’s Ministry of Health and Family Welfare recommend vaccination as the most effective tool against H1N1 virus infections. Other standard measures to control the spread of infection include creating awareness about symptoms, early diagnosis and early treatment of the disease.

In 2010, India’s health authorities started using a nasal spray vaccine against H1N1. Initially, health ministry recommended vaccination of only healthcare workers who came in close proximity of infected patients. In 2015, the health ministry issued an advisory to vaccinate pregnant women and people with certain pre-existing medical conditions who were more susceptible to H1N1 infection. These pre-existing conditions including diabetes, hypertension, and chronic obstructive pulmonary disorders.

In April 2017, the health ministry reiterated these measures to control the spread of infection. The health ministry based its recommendations on data from past outbreaks across the country, which showed that more than 50% of those with H1N1 infections had co-morbidities like diabetes or hypertension. Along with directions to carry out vaccinations, the health ministry’s swine flu guidelines also lay down protocols to prevent the H1N1 transmission, like the use of masks for swine flu patients in hospitals as well as for those infected kept in home isolation.

According to the Dr Umang Mishra, medical officer with the Gujarat health department, most people who died of H1N1 infection in the state were suffering from other co-morbidities. “Many had hypertension, diabetes or chronic obstructive pulmonary disease,” he said.

In fact, audits of 329 swine flu deaths in the state this year show that about 57% were cases of people with pre-existing conditions including diabetes, hypertension and lung ailments.

No vaccination

Despite the health ministry’s advisory to vaccinate these groups of vulnerable people, Gujarat has not carried out vaccinations among high-risk populations.

Health authorities in Gujarat dismissed the need for vaccination to control the spread of swine flu. Dr PV Dave, additional director of health department of Gujarat, told Scroll.in that the department did not consider vaccination and refused to elaborate on other flu-control strategies adopted by the state.

“H1N1 is so common in India that it is called seasonal flu,” said Dave. “The rate of death among accidents is higher but nobody worries about that.”

Dr AC Dhariwal, director of National Centre for Disease Control, said that all high-risk states including Gujarat were asked to follow the guidelines issued by the health ministry to control H1N1 transmission. “It is the responsibility of each state to vaccinate its people,” he said.

Vaccine efficacy

All states that have witnessed H1N1 outbreaks this year have seen similar trends of swine flu deaths among people with other ailments and those with compromised immunity including elderly, children and pregnant women.

In Maharashtra, another state identified as high-risk for H1N1, health authorities have vaccinated more than 30,000 vulnerable people.

“These are just people who took vaccination at our centres, many are taking vaccine from their private doctors,” said a senior health official from Maharashtra who did not want to be identified.

Although Maharashtra has recorded the highest number of swine flu cases and deaths this year, the official claimed that there has been a significant reduction in the number of pregnant women catching H1N1 infections after the vaccine was introduced.

Gujarat has only asked health workers to get vaccinated.

The health ministry advisory states that, when the appropriate vaccine is used for the flu strain in circulation, the efficacy of the vaccine is between 70% and 80%.

“The vaccine works, but it is not 100%,” agreed Dr Om Shrivastav, infectious disease consultant from Mumbai. “Inadequate and delay in treatment have led to a higher morbidity and mortality this year. If people were put on treatment early, the medicine is working well.”

However, Shrivastav stressed that vaccination is the only way to prevent the spread of disease and that one would have to immunise a sizable population for it to work. “We need to vaccinate about 40 to 60% of the people in high risk groups to bring down the infection rate,” he said.

When to vaccinate?

Even if Gujarat starts vaccinating vulnerable groups now, it may not be enough. Vaccinations should ideally be done between April and July, before outbreaks occur.

“Vaccinating people when the transmission is going on may not be of any benefit,” said Dr Lalit Dar, professor of microbiology at the All India Institute of Medical Sciences in Delhi. Dar is a part of a central government team which visited Gujarat to suggest steps to control the transmission of the virus. He said that vaccinations must be carried out before the virus starts spreading.

Dar, however, pointed out that the availability of vaccine in the pre-monsoon period has been a problem in the past. “We are trying to ensure that the flu vaccine for the year reaches Indian markets earlier,” he said. New flu vaccines are developed and manufactured every year as per the virus expected to be in circulation.

Dar said that the spread of the virus is on the decline in Maharashtra and the team anticipates that the number of cases in Gujarat may also decrease within a few weeks.

Change in virus?

Gujarat health officials have said that this year’s outbreak has been due to a change in the H1N1 virus. Genetic changes in influenza viruses occur in two ways. Sometimes, there is an abrupt significant mutation that creates a new strain of virus. The phenomenon is called antigenic shift and can cause dangerous outbreaks like the H1N1 pandemic of 2009. But influenza viruses more often undergo small genetic changes that create viruses that are only slightly different from the original virus. A person who has been exposed to the original virus may have developed immunity to it but will not be immune to this newer version created by such an antigenic drift.

The National Institute of Virology reported such antigenic drifts in H1N1 strains circulating in India. But bigger antigenic shifts have also occurred. The institute said that India has started witnessing the spread of the Michigan strain of the H1N1 virus this year. Earlier, India had recorded cases of only of the California strain.

“We have found that all the cases from Gujarat are of the Michigan strain,” said Dar.

The current vaccine being used by health authorities is supposed to confer immunity against all H1N1 strains in circulation, including the Michigan strain.

Delay in treatment

Doctors treating H1N1 patients in Gujarat said that most patients get to hospital days after the onset of symptoms. Oseltamivir, the only drug which is effective against the H1N1 virus, works best when administered within 48 hours of the patient complaining of symptoms. Those suffering from H1N1 complain of fever, sore throat, running nose and body pain among other symptoms.

“In most cases where patients have succumbed to H1N1, there was a delay in diagnosis and administration of Oseltamivir,” said Dr AN Shah, professor and head of medicine department at Ahmedabad civil hospital in Gujarat.

Most patients who are being admitted to the civil hospital in Ahmedabad, Shah said, were referred from private hospitals and nursing homes. “The doctors there did not suspect H1N1 and only when the patients deteriorated, they referred them to our hospital.”

Even though Gujarat has relatively better rural health services than other parts of the country, Dar suggested that the gaps in healthcare in rural areas have contributed to the delay in treatment and to greater swine flu fatality.

“People from rural areas were reaching hospitals late,” said Dar. “Also many people were neglecting the symptoms of cough and not seeking help early.”

The actress weighs in on what she loves about the show.

All women growing up in India, South Asia, or anywhere in the world frankly; will remember in some form or the other that gentle girlhood admonishing, “Nice girls don’t do that.” I kept recalling that gently reasoned reproach as I watched Sharp Objects (you can catch it on Hotstar Premium). Adapted from the author of Gone Girl, Gillian Flynn’s debut novel Sharp Objects has been directed by Jean-Marc Vallée, who has my heart since he gave us Big Little Lies. It stars the multiple-Oscar nominee Amy Adams, who delivers a searing performance as Camille Preaker; and Patricia Clarkson, who is magnetic as the dominating and dark Adora Crellin. As an actress myself, it felt great to watch a show driven by its female performers.

The series is woven around a troubled, alcohol-dependent, self-harming, female journalist Camille (single and in her thirties incidentally) who returns to the small town of her birth and childhood, Wind Gap, Missouri, to report on two similarly gruesome murders of teenage girls. While the series is a murder mystery, it equally delves into the psychology, not just of the principal characters, but also of the town, and thus a culture as a whole.

There is a lot that impresses in Sharp Objects — the manner in which the storytelling gently unwraps a plot that is dark, disturbing and shocking, the stellar and crafty control that Jean-Marc Vallée exercises on his narrative, the cinematography that is fluid and still manages to suggest that something sinister lurks within Wind Gap, the editing which keeps this narrative languid yet sharp and consistently evokes a haunting sensation.

Sharp Objects is also liberating (apart from its positive performance on Bechdel parameters) as content — for female actors and for audiences in giving us female centric and female driven shows that do not bear the burden of providing either role-models or even uplifting messages.

Instead, it presents a world where women are dangerous and dysfunctional but very real — a world where women are neither pure victims, nor pure aggressors. A world where they occupy the grey areas, complex and contradictory as agents in a power play, in which they control some reigns too.

But to me personally, and perhaps to many young women viewers across the world, what makes Sharp Objects particularly impactful, perhaps almost poignant, is the manner in which it unravels the whole idea, the culture, the entire psychology of that childhood admonishment “Nice girls don’t do that.” Sharp Objects explores the sinister and dark possibilities of what the corollary of that thinking could be.

“Nice girls don’t do that.”

“Who does?”

“Bad girls.”

“So I’m a bad girl.”

“You shouldn’t be a bad girl.”

“Why not?”

“Bad girls get in trouble.”

“What trouble? What happens to bad girls?”

“Bad things.”

“What bad things?”

“Very bad things.”

“How bad?”

“Terrible!!!”

“Like what?”

“Like….”

A point the show makes early on is that both the victims of the introductory brutal murders were not your typically nice girly-girls. Camille, the traumatised protagonist carrying a burden from her past was herself not a nice girl. Amma, her deceptive half-sister manipulates the nice girl act to defy her controlling mother. But perhaps the most incisive critique on the whole ‘Be a nice girl’ culture, in fact the whole ‘nice’ culture — nice folks, nice manners, nice homes, nice towns — comes in the form of Adora’s character and the manner in which beneath the whole veneer of nice, a whole town is complicit in damning secrets and not-so-nice acts. At one point early on in the show, Adora tells her firstborn Camille, with whom she has a strained relationship (to put it mildly), “I just want things to be nice with us but maybe I don’t know how..” Interestingly it is this very notion of ‘nice’ that becomes the most oppressive and deceptive experience of young Camille, and later Amma’s growing years.

This ‘Culture of Nice’ is in fact the pervasive ‘Culture of Silence’ that women all over the world, particularly in India, are all too familiar with.

It takes different forms, but always towards the same goal — to silence the not-so-nice details of what the experiences; sometimes intimate experiences of women might be. This Culture of Silence is propagated from the child’s earliest experience of being parented by society in general. Amongst the values that girls receive in our early years — apart from those of being obedient, dutiful, respectful, homely — we also receive the twin headed Chimera in the form of shame and guilt.

“Have some shame!”

“Oh for shame!”

“Shameless!”

“Shameful!”

“Ashamed.”

“Do not bring shame upon…”

Different phrases in different languages, but always with the same implication. Shameful things happen to girls who are not nice and that brings ‘shame’ on the family or everyone associated with the girl. And nice folks do not talk about these things. Nice folks go on as if nothing has happened.

It is this culture of silence that women across the world today, are calling out in many different ways. Whether it is the #MeToo movement or a show like Sharp Objects; or on a lighter and happier note, even a film like Veere Di Wedding punctures this culture of silence, quite simply by refusing to be silenced and saying the not-nice things, or depicting the so called ‘unspeakable’ things that could happen to girls. By talking about the unspeakable, you rob it of the power to shame you; you disallow the ‘Culture of Nice’ to erase your experience. You stand up for yourself and you build your own identity.

And this to me is the most liberating aspect of being an actor, and even just a girl at a time when shows like Sharp Objects and Big Little Lies (another great show on Hotstar Premium), and films like Veere Di Wedding and Anaarkali Of Aarah are being made.

The next time I hear someone say, “Nice girls don’t do that!”, I know what I’m going to say — I don’t give a shit about nice. I’m just a girl! And that’s okay!

Swara is a an award winning actor of the Hindi film industry. Her last few films, including Veere Di Wedding, Anaarkali of Aaraah and Nil Battey Sannata have earned her both critical and commercial success. Swara is an occasional writer of articles and opinion pieces. The occasions are frequent :).

Watch the trailer of Sharp Objects here:

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This article was published by the Scroll marketing team with Swara Bhasker on behalf of Hotstar Premium and not by the Scroll editorial team.